Fritz J. Baumgartner, MD, Ali Gheissari, MD, Eli R

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Presentation transcript:

Technical aspects of total revascularization in off-pump coronary bypass via sternotomy approach Fritz J. Baumgartner, MD, Ali Gheissari, MD, Eli R. Capouya, MD, George P. Panagiotides, MD, Alireza Katouzian, MD, Taro Yokoyama, MD, PhD The Annals of Thoracic Surgery Volume 67, Issue 6, Pages 1653-1658 (June 1999) DOI: 10.1016/S0003-4975(99)00286-6

Fig 1 Deep pericardial sutures (arrows) placed to elevate the left posterior pericardium for exposure of lateral and inferior walls. Exposure of the ramus intermedius, obtuse marginals (OM), and posterior descending artery (PD) are best achieved by tension on sutures 1-2, 2-3, and 3-4, respectively. The Trendelenburg position further elevates the apex (A). The Annals of Thoracic Surgery 1999 67, 1653-1658DOI: (10.1016/S0003-4975(99)00286-6)

Fig 2 Retractor and stabilizer in position over the left anterior descending artery, the easiest target to graft. The retractor bar is placed inferiorly; the footplate points cephalad. The Annals of Thoracic Surgery 1999 67, 1653-1658DOI: (10.1016/S0003-4975(99)00286-6)

Fig 3 Exposure of the obtuse marginal (OM) as viewed from the head of the table (CE = cephalad). Two deep pericardial suture snares (S) are used to elevate the left pericardium and tilt the apex out of the chest. The stabilizer bar (B) further exposes, positions, and immobilizes the OM. A vessel loop is seen around the proximal OM. The left internal mammary artery (L) has already been grafted to the left anterior descending coronary artery. The Annals of Thoracic Surgery 1999 67, 1653-1658DOI: (10.1016/S0003-4975(99)00286-6)

Fig 4 Exposure of the posterior descending artery as viewed from the surgeon’s perspective. A suture snare (S) in the diaphragmatic pericardium elevates the apex anteriorly and cephalad (CE), as does the Trendelenburg position. The stabilizer bar (B) further exposes, positions, and immobilizes the target. A vessel loop is seen around the proximal posterior descending artery. The Annals of Thoracic Surgery 1999 67, 1653-1658DOI: (10.1016/S0003-4975(99)00286-6)

Fig 5 Cruciate side-to-side sequential anastomosis between the radial artery (R) and ramus intermedius. The distal limb of the radial artery has been grafted to the obtuse marginal. The heart is torqued inferiorly and toward the right, resulting in the greatest chance of tension on the left internal mammary artery to left anterior descending coronary artery anastomosis (arrowhead). The handle of the vascular occluder is seen (O) as well as the loosened silicone-elastomer snare. Note the maneuverability of the stabilizing bar (B), which is nearly parallel with the footplate. The Annals of Thoracic Surgery 1999 67, 1653-1658DOI: (10.1016/S0003-4975(99)00286-6)

Fig 6 FloCoil shunt inserted into opened coronary artery. Internal vascular occlusion is achieved while maintaining perfusion. The Annals of Thoracic Surgery 1999 67, 1653-1658DOI: (10.1016/S0003-4975(99)00286-6)